Appendix 14 -4h App H GT Fee Offset Certification

Authorization ID: #AUTH_ID#
Contact ID: #HOLDER_ID#
Expiration Date: #EXPIRATION_DATE#

FS-2700-4h, App. H (09/2020)

OMB No. 0596-0082

U.S. DEPARTMENT OF AGRICULTURE

FOREST SERVICE

SPECIAL USE PERMIT FOR

CAMPGROUND AND RELATED GRANGER-THYE CONCESSIONS

APPENDIX H

GRANGER-THYE FEE OFFSET CLAIM

AUTHORITY: Section 7 of the Granger-Thye Act, 16 U.S.C. 580d

NATIONAL FOREST

RANGER DISTRICT

PERMIT ID NUMBER

Project Name

Holder’s Fiscal Year (FY)

Total allowable costs may be offset under a Granger-Thye (GT) fee offset agreement to the extent they do not exceed the total annual fee for this permit. Total allowable costs of a GT project included in this GT claim are the sum of the direct GT project costs and indirect costs allocable to this GT project. Costs submitted under this GT claim shall be documented and determined by the Forest Service to be reasonable, allocable, and determined to be allowable, in accordance with the terms of this permit, the applicable GT fee offset agreement, and applicable Forest Service directives. Direct GT Costs: Provide claimed GT costs by cost element and attach schedules to show the cost breakdown by cost element. Provide supporting documentation for the cost claim. Indirect Costs: Indirect costs must be computed based on Forest Service-approved indirect cost rate and may be added to the total direct GT costs. Attach the approved indirect cost rate for FY [ ]. Approval of the fee offset claim is subject to all provisions in the Annual Granger-Thye Fee Offset Agreement (FS-2700-4h, Appendix B) executed by the U.S. Department of Agriculture, Forest Service, [name] National Forest, and [holder name] on [date of GT fee offset agreement].

DIRECT GT COSTS

Salaries and Wages
Materials and Supplies
Subcontracts
Other (specify)
Sum of Direct GT Costs

$
$
$
$
$

INDIRECT COSTS ([

$

]% x Direct GT costs)

TOTAL GT COST CLAIM FOR PROJECT

$

Subject to the penalties prescribed in the False Statements Act, 18 U.S.C. 1001, the holder certifies to the best of its knowledge that the representations in the documents supporting its claim for fee offset are accurate and complete. The Forest Service reserves the right not to grant the fee offset claim if any of

these representations is inaccurate or incomplete. Failure to sign the certification shall vitiate the fee offset claim.
[NAME AND TITLE OF PERSON SIGNING ON BEHALF OF HOLDER,

DATE

IF HOLDER IS AN ENTITY]

#HOLDER_NAME#

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond,